Provider Demographics
NPI:1841181559
Name:GRAY, ROSE
Entity type:Individual
Prefix:
First Name:ROSE
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12425 WESTMINSTER AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-2716
Mailing Address - Country:US
Mailing Address - Phone:310-751-4305
Mailing Address - Fax:
Practice Address - Street 1:512 MAIN ST STE 2
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-3065
Practice Address - Country:US
Practice Address - Phone:310-751-4305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-10
Last Update Date:2025-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA139385103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical